Discover and defeat your diagnostic errors

While statistics show diagnostic error to be common in medicine—responsible
for an estimated 40,000 to 80,000 deaths a year—most physicians don't think
they make many such mistakes, Mark L. Graber, MD, FACP, told attendees at Hospital
Medicine 2017.

But a simple shift in perspective can clarify the problem. “Take off your doctor
hat. Can you recall a diagnosis you were given that was wrong or a diagnosis that
should have been made much earlier? Or is there somebody in your family who has a
medical condition that still causes symptoms but hasn't been diagnosed? That's what
we're dealing with,” he said.

Mark L. Graber, MD, FACP/Photo courtesy of Dr. Graber.

The causes of diagnostic error are both individual and systemic, according to Dr.
Graber, president of the Society to Improve Diagnosis in Medicine, senior fellow at
RTI International, and a leader in the effort to reduce diagnostic error.

“Diagnosis is too important a process to rely solely on our intuition,”
he said. During sessions in the conference's diagnostic reasoning track, he and other
experts offered advice on how hospitalists can reduce their and their hospitals' diagnostic
errors.

Check your work

One reason hospitalists might not think they make errors in diagnosis is because they
never see their patients again. “I bet that most of the outcomes of the patients
that you care for in the health care system are unknown,” said Andrew Olson,
MD, FACP, assistant professor of medicine and pediatrics at the University of Minnesota
in Minneapolis.

Hospital medicine is very focused on conveying important information to other clinicians,
he noted. “I try really hard to call primary care providers after we have a
patient discharged. I try really hard to sign out in a systematic way to my colleague
coming on. But there is no information that goes the other way in any feedback loops,”
he said. “When the patient is readmitted, the discharging physician doesn't
always find out. When the discharge diagnosis is different from the admission diagnosis,
we don't know that either.”

To improve their diagnostic skills and avoid errors, hospitalists need to know whether
they've gotten a diagnosis right or wrong. Although that doesn't happen often now,
it's not that hard to make it a regular practice, according to Dr. Olson.

“The cool thing about hospital medicine is that pretty much every patient will
be seen by more than one person,” he said.

Feedback can be collected individually, for example, by asking a colleague on handoff
to reconsider a patient's diagnosis. “When I work nights, it's really kind
of fun if somebody says, ‘Could you take a look at this case?’”
said Dr. Olson.

Andrew Olson, MD, FACP/Photo courtesy of Dr. Olson.

This practice can identify individual issues as well as more general problems. “If
I find that I'm actually really suboptimal at diagnosing bronchiolitis, my partners
can help me with that and give me feedback about that,” said Dr. Olson.

This review process doesn't have to be lengthy to be effective. “That doesn't
mean we redo the whole H&P,” he said. “I'm not encouraging you
to take an hour for each holdover patient.”

Feedback can also be low tech, Dr. Olson said. “Leave a list for your colleague
of your census on Monday afternoon. They can fill it out on Wednesday: What's their
name? Did their diagnosis change: yes or no, and why?”

Such systems could also be worked into electronic health records. “We all think
we look in the charts, but there's really compelling data saying that we don't. The
patients we look in the chart for are the ones we're worried about,” said Dr.
Olson. “It needs to be automated. When a patient gets discharged that I admitted,
I should get a discharge summary.”

Fear of failure

All this potentially negative feedback might be an intimidating prospect. “All
of us are worried that … the reason the diagnosis changed or evolved is because
I'm stupid. That's not it,” Dr. Olson said, noting that most diagnoses will
change because of new information. “The daughter flew in from California and
gave more information. The test came back positive. The patient spiked a fever the
next day.”

He advocated accepting more uncertainty about diagnosis throughout a hospitalization.
“On day 1, you write this whole big long thing about what the patient might
have or might not have, but on day 2, we stop doing that. Now it's just a diagnosis,”
he said. “Keep the idea of a working diagnosis.”

In cases where the diagnosis is particularly uncertain, that information should be
shared when the patient is handed off. “We are terrible at talking about uncertainty,”
Dr. Olson said. “We assign diagnoses and whether we're sure or not, the note
looks the same. Why don't major transitions of care have a quantification of ambiguity?”

A transition presents an opportunity for a diagnostic timeout, either in your own
head or in conversation with another clinician. “What else could it be? You
don't have to do another test. Just think about it at the time of transition of care,”
he said. Also consider the worst-case scenario, Dr. Olson advised. “What's
the worst thing this could be? Come up with that, because once in a while, you need
to test for it. The great example of that is pulmonary embolism.”

While they're accepting uncertainty, physicians should also acknowledge their own
trouble spots, he said. “How many of you have found that you've had delayed
diagnosis of a spinal epidural abscess in a patient on chronic opioids?” asked
Dr. Olson. “The patient comes in with back pain, and we have certain assumptions.”

Whether it's your patient or your day causing you diagnostic problems, consulting
with a team can help avoid an error. “Has anybody ever had a day where you're
just off or you feel like you can't do it? Give yourself permission to talk about
that,” said Dr. Olson. “Say, ‘You know, I'm just not hitting
on all cylinders today, I need help.’”

Teams and tools

Working with a team was one of the recommendations offered by the National Academy
of Medicine's 2015 report “Improving Diagnosis in Health Care,” Dr.
Graber noted. Team efforts to combat diagnostic error should include other physician
specialties, of course, but also nurses. “Nurses spend a lot of time with our
patients. They are in a great position to know whether our communication was effective,
whether things are playing out the way we think they should,” he said.

Patients should also be considered part of the diagnostic team. “If the patient
is your partner, you have a new safety net. Tell him, ‘I think you have gastroenteritis,
but I'm not sure. If you get worse by tomorrow, you have to let me know,’”
said Dr. Graber.

He reiterated Dr. Olson's advice to consider, and ask others, what else could be causing
the patient's symptoms. “Always make a differential diagnosis. Always. Not
just on the cases you're puzzled about. I'm not worried about those. You'll take plenty
of time on those cases. Do it on the cases you're really sure about,” Dr. Graber
said.

Other online tools can also help, but not the one you're probably thinking of. “Friends
do not let friends use Google for diagnosis,” said Dr. Graber. “The
sensitivity of Google is about 60%, so 40% of the time what you're looking for is
not going to be on that list, as opposed to these engines that have been specifically
designed for diagnosis, which have a sensitivity of 95%, 98%. And the specificity
of Google is zero. It's an unordered list.”

Dr. Graber also offered some advice to hospitalists on fixing the systemic causes
of diagnostic error. “None of these are going to be a surprise to you,”
he said, listing off causes identified by past research, including failures of communication,
coordination of care, subspecialist availability, trainee supervision, and test and
lab reliability.

The problem with everyone's familiarity with these shortcomings of hospital care is
that they become normalized, he explained.

“We get used to the way things are; we don't have time to go report every little
problem to our boss, and if we do, we won't be well thought of anymore. And yet that's
what we need to do to improve medicine,” he said. “Every once in a while—I
don't know what the right interval is, once a month, once a year—bring something
to attention. Say, ‘Hey, this is really bugging me. Can we please fix this
in our system?’”

Each small improvement helps physicians come closer to acing the herculean task of
accurate diagnosis. “I think it's the most difficult cognitive challenge that
humans face,” said Dr. Graber.

How to teach diagnosis

Academic hospitalists face the challenge of not only diagnosing their patients accurately
but also teaching trainees to do the same.

Traditional medical education has not focused much on this process of clinical reasoning,
according to Robert Trowbridge, MD, FACP, director of undergraduate medical education
in the department of medicine at Maine Medical Center in Portland and an associate
professor of medicine at Tufts University in Boston.

Robert Trowbridge, MD, FACP/Photo courtesy of Dr. Trowbridge.

“We need to teach clinical reasoning explicitly and have an explicit focus
on it rather than us just kind of catching diagnostic abilities, which is kind of
what many of us did in training,” he said. “The reason why we haven't
done it explicitly is because it's pretty complicated.”

Dr. Trowbridge offered some strategies for tackling this complicated task during a
talk at Hospital Medicine 2017.

One method is simply to reason aloud. “You have a case presented in chunks
and you say what you think is going on,” he said. “You say, ‘OK,
so 57-year-old with chest pain, we're thinking about ACS [acute coronary syndrome],
we're thinking about [aortic] dissection, maybe we're thinking about PE [pulmonary
embolism]. And the reason why I'm thinking that is x, y, and z.’”

Then have the trainee who is presenting the case provide another chunk of information
and think aloud about that. “You don't have to do it with a differential with
10 billion things. But as soon as somebody says something, you're generating hypotheses
and you're identifying key elements of the history and physical and you need to get
that across to the learners,” said Dr. Trowbridge.

It may also work to assign a resident to think through the case aloud, and the conversation
can happen at the bedside or in the conference room. One challenge is that the reasoning
will sometimes turn out to be publicly incorrect. “You have to be willing to
teach without a net, because you have no idea where it's going,” he said.

Diagnostic reasoning can also be taught through homework assignments. Dr. Trowbridge
suggested asking trainees to come up with three possible diagnoses for a patient.
Then for each, they write down everything that goes toward that diagnosis, everything
that goes against that diagnosis, and everything that you'd often see for that diagnosis
that is missing in this patient.

He also encouraged the use of checklists in diagnosis and teaching. “You have
these mental checklists,” he said. For example, when seeing a patient with
chest pain, you might have a unspoken checklist of the most serious potential causes.
“We often go through that in our minds and don't share that with the learners.”

Applying these tips while teaching should help improve trainees' diagnostic skills,
can be fun, and may have one more benefit, according to Dr. Trowbridge. “By
teaching this, we also get better at this ourselves,” he said. “This
is something we really should be concentrating on. I don't think there's much that's
that much more important.”

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.